Transient azoospermia following rosuvastatin medication for hypercholesterolemia.

The authors report a case of transient azoospermia following hydroxymethylglutaryl-coenzyme A reductase (HMGCR) inhibitor rosuvastatin medication for hypercholesterolemia. While a primary infertile couple with oligoasthenospermia was preparing for an in vitro fertilization program, the male partner had been diagnosed with hypercholesterolemia in a medical check-up and prescribed four-week oral administration of rosuvastatin. No motile spermatozoa were found in the ejaculated semen and urine on the day of follicular aspiration. Azoospermia was confirmed by reexamination in weeks 3 and 7. Spermatozoa appeared in the ejaculated semen in two weeks of drug withdrawal. In week 16, the sperm count and motility increased to the level where intracytoplasmic sperm injection was available.

Do combined psychological stress examinations predict pregnancy outcome in an assisted reproductive technology program?

PURPOSE OF INVESTIGATION: To investigate prospectively if the pregnancy outcome in infertile women undergoing assisted reproductive technology (ART) is predictable by a combination of psychological stress examinations on the day of embryo/blastocyst transfer. MATERIALS AND METHODS: From April 2012 to May 2012, 114 women aged 42 years old or less underwent transfer of morphologically-good embryo/blastocyst(s) in the present in vitro fertilization (IVF) center. Immediately before the transfer, salivary secretion was obtained and frozen. α-amylase and cortisol concentrations were quantified using biochemical assays. In addition, patients were asked to answer General Health Questionnaire 28 (GHQ28) and Zung's Self Rating Depression Scale (SDS) following transfer. The results were compared between the pregnant group and non-pregnant group. RESULTS: There were no significant differences in the age of the infertile couples between the pregnant group and non-pregnant group as well as body mass index of the infertile women. The GHQ28 and SDS scores were similar between the two groups, as were the salivary α-amylase and cortisol concentrations. CONCLUSION: This prospective study failed to demonstrate the predictivity of the pregnancy outcome by psychological stress examinations in infertile women in an ART program, even though these tests were used in combination.

Diclofenac suppository pretreatment in prevention of vasovagal reflex-associated complications for infertile women undergoing local endometrial injury.

PURPOSE OF INVESTIGATION: To assess the effects of the diclofenac suppository pretreatment in prevention of vasovagal reflex-associated complications for infertile women undergoing local endometrial injury (LEI). MATERIALS AND METHODS: Eighty-six infertile outpatients with repeated implantation failure following transfer of morphologically good embryos and/or blastocysts underwent single curettage LEI to improve the pregnancy outcome in the subsequent embryo/blastocyst transfer cycle. Of them, 35 patients chose diclofenac suppository administration prior to LEI, whereas 51 patients did not. The occurrence of palpitations, bradycardia, hypotension, presyncope, and requirement of bed rest was compared between the two groups. RESULTS: There were no significant differences in the demographics between the two groups. The prevalence of presyncope and requirement of bed rest was significantly lower in the diclofenac suppository group than in the control group. The pregnancy outcome was similar between the two groups. CONCLUSION: The diclofenac suppository administration is a low-cost effective method to reduce the risk of the vasovagal reflex-associated complications in infertile women undergoing LEI.

Vaginal preparation with povidone iodine disinfection and saline douching as a safe and effective method in prevention of oocyte pickup-associated pelvic inflammation without spoiling the reproductive outcome: evidence from a large cohort study.

PURPOSE OF INVESTIGATION: The aim of this study was to investigate if vaginal preparation procedure affects the occurrence of oocyte pickup-associated pelvic inflammation (OPU-PI) and the reproductive outcome in an in vitro fertilization (IVF) program. MATERIALS AND METHODS: The occurrence of OPU-PI and the reproductive outcome were compared between 956 infertile patients undergoing vaginal preparation with saline douching alone versus 1,216 infertile patients undergoing a combination ofpovidone iodine disinfection and subsequent saline douching in an IVF program. RESULTS: OPU-PI occurred in four patients (0.042%) in the saline douching alone group, whereas there were no cases in the combination group (p = 0.016). There were no significant differences in the rate of fertilization, morphologically good embryo acquisition, clinical and ongoing pregnancy between the two groups (p > 0.23). CONCLUSIONS: This large cohort study demonstrated that a combination of vaginal povidone iodine disinfection and subsequent saline douching is more effective procedure than saline douching alone to prevent OPU-PI, without spoiling the oocyte quality.

Successful living related kidney transplantation across an anti-donor HLA antibody.

In preconditioning highly sensitized kidney transplant candidates, renal allograft outcomes have been better when the serum titer for class I anti-HLA donor-specific antibody (DSA) is low in the recipient at the time of transplantation. However, the ideal level to which the titer should be lowered is still controversial. We report a primary living related kidney transplant in a 34-year-old highly sensitized woman (pretransplant panel-reactive antibody=70%) with end-stage renal disease secondary to chronic glomerulonephritis. We sought to desensitize by lowering the DSA titer specifically to 1:4 pretransplant. A standard complement-dependent cytotoxicity cross-match with her donor (sister) was repeatedly negative, although she was positive for class I antibody against her mismatched HLA antigen (A*2402) at a titer up to 1:16 by the single-antigen flowbead assay. The target DSA titer of 1:4 before transplant was achieved by 12 sessions of plasmapheresis (PP) over 7 weeks, plus two intravenous immune globulin infusions (IVIG) (500 mg/kg/infusion). The patient outcome was excellent. Neither IVIG nor PP was needed posttransplant. The serum creatinine ranged between 0.5 mg/dL and 1.2 mg/dL, and no rejection episode was documented at 28 weeks posttransplant. Therefore, we encourage the use of IVIG and PP to lower the DSA titer to at least 1:4 before kidney transplantation in highly sensitized patients. Large prospective trials are needed to establish a consensus for pretransplant risk assignment and to evaluate the need for desensitization.

Monoclonal antibody against A1 Lewis d antigen produced by the hybridoma immunized with a pulmonary carcinoma.

A monoclonal antibody (CALed) against a human pulmonary squamous cell carcinoma line was cytotoxic to the line but did not react to an autologous B-lymphoblastoid line. Although the antibody was thought to be cancer specific, principally on the basis of this evidence, the antibody actually had the A1 Lewis d (Led) specificity. It reacted with approximately 2% of the random donor T-lymphocytes and with all six lymphocytes from donors who were A1 Led type without reacting to lymphocytes of any other type. The monoclonal antibody reactivity was also absorbed out by A1 Led red blood cells but not by red cells of other types. We conclude that the A1 Led antigen had been synthesized by the pulmonary carcinoma lines but not by the autologous lymphoblastoid line, resulting in disparity for this antigen. Since the combination A1 Led only occurs in 2% of the population, it is difficult to distinguish this type of antibody from tumor-specific antibodies.

Molecular cloning and characterization of the epididymis-specific glutathione peroxidase-like protein secreted in the porcine epididymal fluid.

The epididymis-specific glutathione peroxidase was purified from the porcine cauda epididymal fluid in order to analyze its enzymatic activity and roles in the epididymis. The purified protein was found to consist of four identical 23 kDa subunits. The complementary DNA encoding the 23 kDa subunit was cloned from the cDNA library of the porcine proximal caput epididymis, only where the 23 kDa subunit is expressed. Although the selenocysteine codon (TGA) is contained in the cDNA of the other cytosolic type of glutathione peroxidases, it is replaced by cysteine codon (TGT) in the 23 kDa subunit cDNA, similarly to the results previously obtained for cDNAs encoding the epididymis-specific form of the secreted glutathione peroxidases of mouse, rat and monkey. By the direct analysis of the selenium, the purified protein was proved to contain no selenium atom in the molecule. The activities of the purified epididymis-specific glutathione peroxidase toward hydrogen peroxide or organic hydroperoxides were by far lower than the activity of cytosolic selenium-dependent glutathione peroxidase (less than 0.1%). In addition, the concentration of glutathione in the porcine epididymal fluids was about 20 microM, which is much lower than the optimal concentration for the glutathione peroxidase activity of the purified protein. These results strongly suggest that this protein is enzymatically quiescent at least in the porcine epididymal fluid. An immunocytochemical study showed that this protein was found to bind to the acrosomal region of the epididymal sperm and to disappear during the acrosome reaction. Furthermore, this protein significantly retarded the acrosome reaction induced in vitro. The possibilities have been discussed that it protects sperm from the premature acrosome reaction and maintains sperm fertilizing ability in the epididymis.

HLA-DR specifications in Japanese with juvenile-onset insulin-dependent diabetes mellitus.

Specific allelic associations vary among ethnic groups. We studied the distribution of HLA-A,-B,-C, and -DR antigens in 34 Japanese juvenile-onset diabetic patients. The focus of our current work was HLS-DR antigens because there have been few studies of Japanese with this disease. A significant increase in the frequency of HLA-DR4 was found in patients but not in unaffected persons: DR4 was found in 56.3% of the patients versus 32.6% of the unaffected persons. However, the negative correlation between DR2 and patients was not statistically significant.

Renal biopsy donor group: the influence of glomerulosclerosis on transplant outcomes.

The UNOS donor population was examined from 1999 to 2002, and approximately 25% of the over 23,000 donors were biopsied (Bx). There was a significant trend (P < .001) of older donors, cardiovascular accident, and hypertension in the Bx group versus the non-Bx group. The percent GS was directly correlated (P < .001) to graft survival, delayed graft function, and primary nonfunction. Cox regression showed significant relative risk (RR) for >10% GS, hypertension, donors over the age of 50, and African American recipients. RR in donors with >10% GS could be ameliorated (P < .001) by choosing donors with <5 HLA-A, -B, or -DR mismatches (MM), or recipients who were nonsensitized, and/or first transplant. Risk should be managed in donors by choosing appropriate recipients and high-risk immunosuppresion protocols.

Average P/F ratio during donor management for finding out the potential donor of lung procurement.

We investigated the potential donors from cases without lung procurement in spite of considering procurement as the donor. We reviewed 207 cases considered for lung procurement. Donors were divided into 2 groups according to whether or not their lungs were harvested: 50 did and 157 did not. We investigated their age, gender, donor management periods, blood pressure, heart rate, P/F ratio, PCO2, HCO3, positive end-expiratory pressure (PEEP), respiratory rate, abnormal findings in the chest X-ray, blood chemistries, sputum culture, and intravenous administration of steroid. Univariable or multivariable logistic regression analysis was used to predict lung harvesting by various factors. Univariable logistic regression analysis revealed maximum heart rate (HR) and respiratory rate (RR), maximum, minimum, and average P/F ratio, and abnormal findings in the chest X-ray, to be predictors to perform transplant. The maximum HR and RR of the non-harvest group are higher than those of the harvest group. Multivariable logistic regression analysis revealed average P/F ratio only to be a predictor to transplant. We divided the non-harvest group into 2 groups according to whether or not their P/F ratio was >300: 55 did (P/F 300 group) and 102 did not (P/F 299 group). Between P/F 299 group and the harvest group, univariable logistic regression analysis revealed maximum HR, maximum and minimum RR, maximum PEEP, maximum, minimum, and average P/F ratio, and abnormal findings in the chest X-ray to be predictors to transplant. Maximum HR, PEEP, and maximum and minimum RR of the P/F 299 group are higher than those of the harvest group. Maximum, minimum, and average P/F ratio of the P/F 299 group are lower than those of the harvest group. The average PCO2 of P/F 299 group is higher than that of the harvest group. The rate of abnormal findings in the chest X-ray of the P/F 299 group is higher than that of the harvest group. Multivariable logistic regression analysis revealed average P/F ratio only to be a predictor to transplant. There were no predictors between the P/F 300 group and the harvest group in both univariable and multivariable logistic regression analyses. Furthermore, there were no different factors between the P/F 300 group and the harvest group. Our study showed that 35.5% of the non-harvest group had a P/F ratio of >300 and had no difference compared with the harvest group. Our data suggest that potential donors existed in the non-harvest group and increased the number of lung procurement to 27.3% from 13.0% of all donors.

The transfusion effect in cadaver kidney transplants--yes or no.

The transfusion effect in first cadaver kidney transplants was re-examined at the UCLA Transplant Registry. One-year graft survival rates were 71% for non-transfused patients, which improved to 75% (P less than 0.05) with a single transfusion, 77% (P less than 0.01) with 2, and 78% (P less than 0.01) with 3 and 4 transfusions. One-year graft survival rates did not improve further with additional transfusions but remained at the same level. Thus, the transfusion effect clearly does exist, and 2 to 4 transfusions are sufficient to obtain the maximum beneficial transfusion effect. Patients with zero HLA-DR mismatched transplants had no blood transfusion effect. Transfusions improved the 1-year graft survival rate by 8% for transplant recipients with 1 DR-mismatched grafts (P less than 0.01) and by 10% with 2 DR-mismatched grafts (P less than 0.01). The transfusion effect was greater in Black than White recipients; however, the 77% 1-year graft survival rate for transfused Black recipients of zero DR-mismatched kidneys did not differ from that of transfused comparably matched Whites. We conclude that transfusion protocols should not be abandoned unless patients receive zero DR-mismatched kidneys.

Evaluation of sequential serum interleukin-6 levels in liver allograft recipients.

Control serum levels of IL-6 measured by ELISA in 30 healthy blood donors or volunteers were 18 +/- 34 pg/ml (mean +/- SD). Pretransplant serum levels of IL-6 in 169 adult candidates for liver transplantation were significantly higher than control in those with fulminant hepatitis (203 +/- 232 pg/ml), alcoholic cirrhosis (116 +/- 257 pg/ml), and hepatocellular carcinoma (82 +/- 105 pg/ml). With these data as background, plasma or serum levels of IL-6 were monitored in 24 adult patients after first OLT and correlated with the clinical courses and the histopathological diagnosis of rejection. Serum or plasma levels of IL-6 decreased after transplantation regardless of pretransplant value. Four patients with infection subsequently developed continuously high IL-6 values. In the 20 of 24 patients who did not have infection, significantly higher levels of IL-6 were consistently found 0-4 days before histopathological diagnosis of rejection (131 +/- 78 pg/ml) compared with significantly lower values in patients without rejection episodes (40 +/- 21 pg/ml). The elevations of IL-6 were spike shaped, did not correlate well with the histopathological grades of rejection, and were highly responsive to augmented immunosuppression. These 20 cases were classified as: group 1, no spikes of IL-6 after liver transplantation; group 2, single spike of IL-6 after liver transplantation; and group 3, multiple spikes of IL-6 after liver transplantation. The combined early and late graft loss of each group was 0% (group 1), 25% (group 2), and 67% (group 3). We conclude that daily monitored serum or plasma IL-6 levels can be a good premonitor of liver allograft rejection and also a useful predictor of long-term graft outcome.

Association of anti-F(ab')2 antibodies with higher kidney transplant survival rates.

When the pretransplant sera of cadaver donor transplant patients were divided into 132 with anti-F(ab')2 (Fab) antibodies and 121 without anti-Fab antibodies, those patients with the antibodies had a 2-year graft survival rate of 59.7 +/- 4.6% (+/- SE) as compared with 34.0 +/- 5.0 % (+/- SE) for those without antibodies (P less than 0.001). This difference was greater when the patients were further classified by whether they had antibodies reactive to B lymphocytes in the cold. Patients with anti-Fab antibodies and B-cold antibodies had a 2-year graft survival of 81.3 +/- 9.8% as compared with 15.7 +/- 7.9% for patients without anti-Fab antibodies and with B-cold antibodies. We suggest that these anti-immunoglobulin antibodies may function in some immunoregulatory role. The number of transfusions was not directly related to the frequency of occurrence of these antibodies.

Examination of the clonal deletion hypothesis following transfusions in rat cardiac transplants.

To test the clonal deletion hypothesis, different levels of immunization were carried out by 0, 1, 2, or 3 transfusions preoperatively, together with 10 methods of immunosuppression. In this way, it was hoped that we could determine the optimal way to immunize and the optimal immunosuppressant treatment to deactivate the responding cells. With the Buffalo-to-Lewis rat heart allograft model, the control mean survival rate was 7 days. Rats with 2 or 3 transfusions had 5- and 12-day survival rates, respectively. If azathioprine was given in addition before grafting, 19- and 18-day survival rates were seen, and if azathioprine was given after grafting, extended survivals of 33 and 34 days were achieved. The longest survival rate of greater than 52 days was obtained by a single transfusion and 25 mg/kg/day of cyclophosphamide given before transplantation. Splenectomy following 2 or 3 transfusions prolonged survival rates to 16-18 days, suggesting that mechanical removal of immunized cells is somewhat effective. Most of the antibody produced by one transfusion was IgM, as were antibodies that resulted from transfusions followed by azathioprine. It is possible that reduction of IgG-producing cells is important. These results are consistent with the clonal deletion theory, although they do not necessarily provide final proof. The experiments suggest that the optimal transfusion effect may be obtained with minimal immunization (1 transfusion) and proper immunosuppression before transplantation.

The benefit and underutilization of sharing kidneys for better histocompatibility.

The data of the UCLA Kidney Transplant Registry were reviewed with regard to sharing. The percentage of first-cadaver cyclosporine-treated transplants since 1984 with long cold ischemia time increased with sharing distance: 25% of unshared grafts, 40% of locally shared, and 61% of distantly shared ones had cold ischemia times over 24 hr; for cold ischemia times over 36 hr the numbers were 6%, 12%, and 24%, respectively. The immediate function rate did not parallel sharing distance the way cold ischemia time did: 85.7% without sharing, 74.4% with local sharing, and 83.5% with distant sharing. The percentage of well-matched (0 HLA-B,DR mismatches) transplants was low (3-5%) regardless of sharing status. Well-matched shared grafts with cyclosporine immunosuppression had a 9% survival advantage at one year compared with poorly matched unshared ones (85% vs. 76%). Long-term, well-matched shared grafts had a half-life of 11.9 years compared with 7.5 years for poorly matched unshared ones (reflecting graft loss from 3 to 10 years posttransplant). We conclude that sharing for histocompatibility has an overall beneficial effect.

Low-dose cyclosporine maintenance therapy after immunosuppressive induction in a rat cardiac transplant model.

An immuno-reduction-suppression protocol using spleen cell infusion followed by cyclophosphamide (CP) or azathioprine (AZ) to reduce the immunocompetent cells and maintenance suppression with low-dose cyclosporine (CsA) was highly effective in a rat cardiac transplant model. Following one or two spleen cell infusions, AZ or CP treatment was given before transplantation. After transplantation the animals were maintained with low-dose CsA. Among those treated with AZ, five of eight survived greater than 100 days, and among those treated with CP, six of eight survived greater than 100. These two protocols were far superior to 28 other permutations of treatment consisting of 164 transplants, such as infusions plus AZ without CsA and infusions without AZ but with CsA. We conclude that CsA can most effectively be used in low dose as a maintenance drug and that immunoreduction therapy is optimized by prestimulation and expansion of reactive cells. Another important feature of this proposal is that the immunoreductive risk phase, performed before transplantation, can be separated from the operative risk period. This avoids the conventional superimposition of the two risks.

Crossreactivity between human and canine Ia antigens using a mouse monoclonal antibody (CIA).

A mouse monoclonal antibody (CIA) produced against human Ia antigens that reacts with 20-30% of human peripheral blood lymphocytes was found to react with more than 90% of dog lymphocytes. Less than 41% of the Ia-positive dog lymphocytes expressed surface immunoglobulins. Immunoprecipitation studies with 125I-labeled cells precipitated heavily labeled Ia bands at 28K and 35K from human cells, but from dog cells the 29K beta chain of Ia was much more heavily labeled than the alpha chain.

B cell antibodies and crossmatching.

Over 200 cadaver donor transplants were crossmatched against T and B lymphocytes at 5 and 37 C. Of 54 positive B cell crossmatches, one-half had cold antibodies and one-half had warm antibodies. The 1-year transplant survival was 58% for B-cold-positive crossmatches and 42% for B-warm-positive crossmatches. The B-warm-positive crossmatches, when subdivided into those with strong HLA-DR antibodies showed a 27% 1-year transplant survival rate. We conclude that B cell-positive crossmatches with HLA-DR antibodies are deleterious and that those with cold anti-IgM antibodies may enhance graft survival.

Prolongation of second heart transplants in rats.

Second clinical kidney grafts often survive longer than first grafts. Using a rat cardiac allograft model, we examined the conditions under which survival of a second graft can be longer than first graft survival. In the BUF-to-LEW combination, following rejection of the first transplant, second cardiac allografts from the same donor strain implanted immediately survived longer than the first grafts (P = 0.047). Although the mean survival time of first grafts was 9.0 days, second grafts implanted in the same animals survived 19.5 days. In contrast, when ACI donors were used for the same LEW recipients, the second grafts were rejected in 3 days compared with 6.6 days for first grafts. Donor-specific spleen cell transfusions in these combinations resulted in prolonged survival in the BUF to LEW combination, but had no effect when the donor strain was ACI. Second grafts from BUF had prolonged survival following rejection of the first graft. Thus the histocompatibility difference was a determining factor of whether or not prolongation would be obtained. Another factor was timing of the second transplant. If 7 days were allowed to elapse following rejection of the first graft before implantation of the second, the enhancement effect was lost. Moreover, in the LEW-to-ACI combination in which second grafts were rejected rapidly, removal of the first graft after 7 days (before rejection), resulted in prolonged survival of the second graft. There is, therefore, a window of time before rejection of first grafts and shortly thereafter, when the enhancement effect can be obtained. Passive transfer of serum in the BUF-to-LEW combination resulted in enhancement, but transfer of splenic cells was ineffective. We conclude that graft rejection can result in induction of enhancement during a specific period, after which this effect is lost; and that enhancement can be obtained only in certain strain combinations. This suggests that human patients with heart transplants that reject might benefit from a second graft, even from a donor with a mismatch similar to the first graft.

An alternative to cadaver kidney transplants for patients with insulin-dependent diabetes mellitus.

The benefits of successful kidney transplants for patients with end stage renal disease associated with insulin-dependent diabetes mellitus are well known, and the potential advantages of earlier transplantation have been emphasized in other reports. Cadaver transplants, which are not always available for these patients, have not provided a high degree of success in many centers. This has discouraged the use of transplants unless well matched related donors are available. Most patients do not have well matched family members who are able to donate. We have attempted to increase the availability of related transplants for diabetic patients by using a new protocol in which related donors who are poorly matched by mixed lymphocyte culture (MLC) testing (stimulation index (SI) greater than or equal to 7) can often serve as the source of the transplant. This protocol of pretransplant donor-specific transfusions (DSTs) has been applied to 20 diabetic patients. Sixteen transplants have been performed after serial immunological studies following the DSTs detected no specific evidence of recipient sensitization to the respective transfusion donors. Only one of the transplants has been rejected, and this occurred in a patient who intentionally terminated immunosuppressive therapy. Graft survival for the group of 16 patients is 93 and 84% at 1 and 3 years, respectively. The quality of renal function for most of the patients is very good, with a mean serum creatinine of 1.9 and 1.5 ml/dl for those transplants at risk for 12 and 24 months. This new method has given encouraging results for poorly matched related transplants in diabetic patients and makes earlier transplantation possible by providing an alternative to cadaver transplants.